If you work in healthcare, it is assured you’ve heard the term supervision a lot. Non-Physician Practitioners are supervised, Physician supervised services, general supervision, direct supervision, personal supervision. In the suite, out of the suite, counter signature. These are elements of supervision, and are exactly what adds to the layers of confusion regarding supervision.

Special Considerations:

  • Was the test ordered by the treating physician?
  • Will the test results be used by the physician to provide management of a medical condition?
  • Service type- Is it eligible to be performed in supervisory situation?
  • Supervisors (Physicians) are you available during performance of the service, in person, or by phone? Have you reviewed the documentation, do you need to counter sign?
  • Is the provider of service a Physician Assistant? Special exception applies to PAs performing diagnostic tests (see CMS clarification below).
  • Are there any carrier, State, and/ or Federal regulations that you may need to be aware of?

Who can perform the service? Non-physician practitioners (NPPs) defined by CMS as clinical nurse specialists, clinical psychologists, clinical social workers, nurse-midwives, nurse practitioners, and physician assistants, who provide physician services, and who are operating within the scope of their authority under State law and within the scope of their Medicare statutory benefit are eligible to perform “supervised” diagnostic tests.

CMS defines supervision of diagnostic tests in CFR § 410.32 as:


CMS clarifies, “However, diagnostic tests performed by a physician assistant (PA) that the PA is legally authorized to perform under State law require only a general level of physician supervision.” This means that the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required.

Further CMS breaks physician supervision down into 6 levels this chart should be used in tandem with the supervision definitions provided above:


NPPs take notice your employment contract, which speaks to “supervision”, may not fully encompass, CMS, CPT, and State level supervision requirements. Research your State regulations, specifically scope of practice and signature requirements. For example Pennsylvania requires all NPP created documentation to contain a physician supervisor counter signature, as well as timely addition of said signature.

See in the chart below an example of applying the definition of supervision and its level designation to specific CPT codes. Many are surprised to find a test like spirometry with bronchodilation responsiveness, code 94060, requires direct supervision. Which means the physician must be present in the suite when the test is performed.